A woman visited a pharmacy to collect a prescription for
mesalazine (Pentasa) which is used to treat ulcerative colitis, and
atorvastatin (Lipitor) which is a cholesterol-lowering medication.
The sole pharmacist on duty at the pharmacy that day dispensed her
medications, intentionally replacing Lipitor with another brand of
atorvastatin, Zarator. The pharmacist mistakenly dispensed
Salazopyrin instead of Pentasa. Salazopyrin is another
medication used to treat ulcerative colitis, but it can cause liver
abnormalities. The pharmacist did not speak directly to the woman
when she enquired with a shop assistant about the change from
Pentasa as he mistakenly believed she was querying the change from
Lipitor.

The woman started taking the medications dispensed by the
pharmacist. She began to feel extremely fatigued and took time off
work. Her blood test results were markedly deranged, and her GP
discovered that she had been taking Salazopyrin in place of Pentasa
for approximately three weeks. The woman was admitted to hospital
with a primary diagnosis of deranged liver function. The overall
opinion was that her condition was caused by a reaction to
Salazopyrin. The woman was discharged from hospital after five
days.

The pharmacy had relevant Standard Operating Procedures in place
at the time, and the pharmacist accepts that he did not follow the
checking procedure required by the Standard Operating Procedure.
The pharmacist failed to ensure that he dispensed the correct
medication and failed to counsel the woman effectively about her
medications, resulting in a missed opportunity to identify the
error at the outset. It was held that the pharmacist did not comply
with professional standards and breached Right 4(2).

The error occurred as a result of the pharmacist's individual
conduct as opposed to systemic issues at the pharmacy. Therefore,
the pharmacy was not held vicariously liable for the pharmacist's
breach.

Adverse comment was made about another pharmacist at the
pharmacy in relation to a later interaction with the woman when she
raised concerns about changes to her medication.